[ FYI, the title of this post is a playful tribute to the National Museum's current Impressionist painting exhibit. ]
Yes, dear readers, Singapore MD is attempting to resurrect itself from a 6-month-long slumber.
And no, our silence is not the result of The Powers That Be shutting us down. That usually entails an actual deletion of the blog, which clearly hasn't occurred here.
Still, one requires some form of inspiration in order to keep a blog running, and I found mine today.
Ironically, thanks to the MOH, muah-ha-ha-ha-ha... :)
A fellow colleague who worked the afternoon shift in the A&E yesterday described a bizarre phone conversation with someone who identified himself as part of the MOH administration's $$$ department. ( p.s. The symbols $$$ were chosen semi-randomly. )
Mr. $$$ asked what our waiting times were like, because he was contemplating arranging for our department to "help see Hospital X's A&E patients". Hospital X being another public institution belonging to the same cluster, but located in another corner of the island, i.e. far far away.
When my friend answered the call, she was up to her neck in cases, with patient trolleys crammed into every available nook, including the corridor just outside the P2 area. She very wisely told Mr. $$$ to speak to our HOD, after which she didn't hear from him again.
Here're a few burning questions for Mr. $$$ and/or the MOH:
1) Why didn't the query go through "proper channels" - i.e. boss to boss? Who in the world is this mysterious Mr. $$$, and why did he call the busy senior doctor on duty, when he should have called an administrative staff ( e.g. our HOD, or at the very least, department manager ) instead?
2) Shouldn't our hospital's own Powers That Be be consulted as well? Shunting A&E patients from one place to another doesn't isolate the problem to the A&E. What if they need admission? Surgery? High dependency or intensive care management? Do we have the capacity to accomodate transfers when we're already bursting at the seams?
3) Does the MOH really think waiting times accurately reflect an A&E's ability to handle patient loads? Short waiting times don't equal low attendances. Perhaps the turnover rate is high because our doctors are pushing themselves to the limit, skipping meals and toilet breaks in order to clear the queues? Most patients who have been seen don't leave the department quickly either. They hang around waiting for test results, specialist consults, procedures, admissions, and the A&E doctors who first attended to them also need to stop their queues frequently for reviews.
Plus, the limited space poses a huge problem for those in the P2 / critical care area. Such cases are usually seen within an hour, but once the observation ward fills up - trust me, this happens daily - the trolleys have nowhere to go, and walking routes become non-existent.
4) What is the exact reason Mr. $$$ feels compelled to ask us to help Hospital X? What is the casemix of the backlog there? P3 walkers, P2 trolleys or P1 sickies? If it's the first, make them wait! If the second or third, redistribute your MOs and make the P3 cases wait even longer ( or just tell them to see their GPs / polyclinics if their complaints are minor ). Or how about sourcing for ward MOs to come down and help? Short of a mini-mass casualty or worse, diversion should be considered the last resort.
MOH and our cluster / hospital's Powers That Be, for your attention please.
Just to re-iterate a point I made earlier...
Why health care is like water
DEPUTY Prime Minister Tharman Shanmugaratnam's proposed review of improved financing, regulation frameworks and clinical programmes to better integrate private and public health-care services bodes well for both health professionals and users ("Private sector to ease health care load?"; July 10).
While the mainstay of health care remains within the public sector, the private sector has reservoirs of reserves locked within, awaiting deployment once the Government can integrate the two with policies to overcome the major obstacles of cost containment and efficiencies.
Health care is a commodity that should be treated the way the Government treats water: essential and affordable, but with a price commensurate with its worth.
Like water, it starts with conservation of health through a conducive lifestyle.
Primary health care that is priced too cheaply and used as a political tool to garner popularity will be abused and fraught with wastage. Tertiary health care in hospitals will also be saddled with unnecessary and frivolous referrals.
However, the removal of the fee schedule for doctors, because it was deemed anti-competitive, has moved the cost of private health care sometimes to stratospheric levels.
A middle ground is sorely needed where general practitioners can practise good medicine without the price pressures generated by insensibly subsidised polyclinics; where private specialists can act as a valuable release valve from heavily utilised public hospitals, if only patients are assured that charges are capped at a fixed premium.
Dr Yik Keng Yeong
Well, I don't think that healthcare is like water - for one thing, healthcare doesn't fall from the sky like water, and I don't agree that the government automatically has rights over all the healthcare that falls onto Singapore...
But I certainly agree with Dr Yik's observation that:
Primary health care that is priced too cheaply and used as a political tool to garner popularity will be abused and fraught with wastage. Tertiary health care in hospitals will also be saddled with unnecessary and frivolous referrals.
Dr Yik recognises that abuse is a problem, and he diagnoses correctly (in my opinion) the reason why abuse is not tackled. However, by proposing that we solve this problem by re-siting patients to the private sector and making it attractive for the patients to want to be re-sited by capping how much doctors there can charge is merely punishing them for the lack of moral courage on the part of the politicians.
The problem, as Dr Yik has pointed out, is the "anti-competitive" "price pressures generated by insensibly subsidised polyclinics"; so if you cap GPs' charges at equal to or below that, then how will they make any profit? Or, if you cap the charges at higher than the polyclinics', then why would patients then choose to see a GP and pay more?
The way I see it, the real reason why abuse occurs is because we have a system where people are not required to pay for what they consume. As long as you are not willing to change that, you will have abuse; until you are willing to change that, or until you are willing to police for and stop abuse if you find it, the problem will remain with you.
The exodus of doctors from the public sector continues to draw attention, as evidenced by recent Straits Times articles and Forum Page letters.
I'm glad that the ST's original feature - which suggests that money is the predominant draw to private practice - was quickly rebutted.
An invitation to a "physician engagement" luncheon 2 weeks ago helped debunk the myth further. With approximately 12 clinicians and 5 senior administrators ( also medically trained ) in attendance, it was a candid affair, allowing us to share concerns from the ground and suggest changes to ensure equal recognition for all areas of expertise.
While institutions currently favour those who conduct research, others who perform clinical duties full-time should not be overlooked. After all, without the latter serving as the department's backbone, the former may not be able to continue with what they're doing in the first place. What's the use of pioneering some new-fangled therapy, when there's no-one left to see patients in the wards and clinics?
Another issue that was highlighted: constraints imposed by the new residency programmes, especially in high-volume areas like polyclinics. Due to the stipulated limits on patient loads and working hours, it's obvious that non-residents will be required to bear the extra burden of clearing the backlog. This may in turn breed discontent among colleagues, resulting in more resignations.
One surgeon even remarked that the narrow scope of training for residents might render them less competent in the long run, compared to their predecessors who underwent the proverbial baptism of fire. And I agree with his prediction. Seeing few patients = less experience = poorer clinical judgment and procedural skills = suboptimal patient care.
And for the benefit of the administrators and corporate communications personnel: suboptimal patient care = more complaints = more lawsuits = hospitals lose more money settling out of court.
While the luncheon was attended by consultants, I hope that registrars are or will be included as well. Because they're the ones who tend to be treated like slaves, working inhumane hours, getting arrowed for everything, and unable to say no as they're the most junior in the department and are too afraid to offend their seniors.
As for the medical officers, they generally have it pretty good these days. Even the non-residents get to do half-calls, so instead of working 24- to 30-hour stretches, they come in at 9pm and go home the next morning. House officers also benefit from ECG technicians and phlebotomists in the wards. I never enjoyed any of these luxuries!
So it remains to be seen whether changes will be made, and how soon they will be implemented. I'd like to stay optimistic for now, and have faith in at least one of our leaders ( who was present that day ).
Let's hope it won't be another case of "all talk, no action".
This news story made me smile:
Police to measure "the cost of crime"
SINGAPORE: In what will be the first study of its kind here, the Singapore Police Force (SPF) will commission an academic study to calculate the cost of the different types of crime committed here.
Modelled after a United Kingdom (UK) government research paper - The Economic and Social Costs of Crime - the study plans to use a "social cost approach" to measure the cost of crime in Singapore.
In response to Today's queries, police spokesperson Choo Hong Xian said the study "would provide valuable insights into operational policy-making, resource reallocation and police's strategies to deliver the mission".
The police release statistics on the overall crime situation here every six months but they relate usually to the number of cases, identifying key crime concerns and providing crime prevention advisories.
According to tender documents released last week, the study aims to derive the annual total cost of crime last year and "a preceding period stipulated" by the police. The final report from the study is expected to be delivered to the SPF within four months of the award of the tender, which closes on July 18.
Overall crime here fell by 0.6 per cent last year but the police highlighted three key crime concerns - cheating cases involving rental scams and phone scams, fighting youth crime and outrage of modesty cases.
The study aims to calculate the costs incurred as a consequence of crime, which includes "monetary loss in traditional terms" and "monetising the loss of life and trauma suffered by victims".
Costs of crime prevention and enforcement will also be tallied. The study seeks to find out costs borne by private entities - such as security expenditure and insurance - as well as costs borne by public bodies such as proactive police patrols in anticipation of crime.The police also intend to calculate the costs incurred in response to crime - investigating cases, apprehending suspects as well as the costs expended by the State in prosecuting, convicting and incarcerating suspects.
Several Members of Parliament had previously raised concerns over police resources being stretched. During the Committee of Supply debate in March, then-Home Affairs Minister K Shanmugam pointed out that while police resources will be increased, "they are not limitless".
While costs of crime prevention - such as installing alarm systems - and the State's response to crime could be measured, sociologist Paulin Straughan felt it might be "impossible" to measure the social costs of a spate of violence on a community. Social isolation and mistrust from these crimes would impact social capital on a community which would be difficult to estimate, she argued.
However, the former Nominated Member of Parliament felt calculating the cost of crime would serve as "a reality check" for any society.
"We live in a world that is driven by economics," Associate Professor Straughan said. "We can't understand or appreciate unless it is documented in dollars and cents. So, this is one way of documenting it (crime) in dollars and cents to show you that every burglary cost you this (amount) … and highlight the importance of crime prevention."
The UK study, published by its Home Office in 2000, found that crime in England and Wales cost society £60 billion (S$118.8 billion) a year, or more than £1,000 for every person.
Every murder cost the country an estimated £1.1 million, vehicle theft and robbery £4,800 and criminal damage £510 pounds, according to the Home Office report.
Assistant Professor Irene Ng Yue Hoong, who researches on youth crime and poverty at the National University of Singapore, felt any study on the costs of crime control should take into consideration the benefits from a decrease in crime.
"Do the marginal costs of crime control justify the marginal benefits from the marginal decrease in crime?" she wondered. "It will be interesting to study whether Singapore's crime control is at an optimal level in terms of the marginal benefits net of marginal costs."
As with healthcare and other valuable services, police work costs money; but as the cost is not borne by the user, the true cost is hidden and abuse occurs. Does this study by the SPF signal a desire on the part of the government to shift the cost of security from the public to the direct consumers? I certainly hope so. Now there will be people who will tell you that you cannot put a price on security (and health) - the truth is, you can: they just don't want to pay for it.
Scarlet fever, Hong Kong
Wednesday, June 22, 2011 | Labels: epidemic, Hong Kong, scarlet fever, Streptococcus pyogenesFor the past few days, an increasing number of Hong Kong children have been diagnosed with scarlet fever, with two deaths to date. The Hong Kong Centre for Health Prevention now posts daily updates here. So far, one kindergarten in Sha Tin district has been closed, while two other schools in Kowloon and Yuen Long districts have reported cases.
There are probably many others, but I shall just focus on two today:
The subject of GPs doing aesthetics came up again recently when Dr Woffles Wu wrote a letter to the ST Forum, arguing that liposuction should only be done by specialists.
MOH replied today; while I have no opinion on whether GPs should be allowed to perform liposuction, the final paragraph of the letter disturbs me:The ministry is in the process of strengthening our primary- care sector by enhancing the training of GPs so that more of them could function as family physicians. This will eventually help to improve our primary-care capability, especially in managing chronic diseases in our ageing population.
Now the 'problem' of GPs doing aesthetics has two parts to it: "why don't GPs do primary-care?" and "why do GPs do aesthetics"?
The answers to the two questions are largely related: to the first part it's because GPs do not see doing primary-care work as rewarding to them, and to the second part it's because they see doing aesthetics work as rewarding. However, it would be wrong to think that if we stopped them from doing aesthetics it will automatically mean that they will all turn to primary-care work, specifically to "managing chronic diseases in our ageing population". They can still make a living 'selling' MCs and 'lifestyle' medications (remember this?), or running a high-volume low-quality corporate contract practice, or doing "health screening", where "problems" are "diagnosed" but not treated (that's where the lucrative end of the business is, you see...).
In other words, 'GPs doing aesthetics' is not the root of the problem for 'GPs not doing primary-care', but a symptom. If you stop GPs from doing aesthetics, then they will likely find something else to 'do'. We can only hope that it's not something like Subutex...
So why don't GPs want to do primary-care then? Is it, as Dr Chern seems to suggest, that they don't know how to? That they need more "enhanced" training before they can even "function" as family physicians? Now bear in mind that we are talking about doctors who have invested the time and money into learning how to perform the various treatment modalities that aesthetics encompasses, not to mention the equipment cost. You do not wake up one morning and say to yourself: You know what? I think I'm going to do aesthetics today. Dr Chern tells us that to do liposuction, a GP has to "be accredited by the Accreditation Committee on Liposuction (ACL) and their medical clinics have to comply with specific licensing conditions". Are such people really incapable of functioning as family physicians?
Now even if that was true - let's just assume for argument's sake that a doctor who has gone through housemanship is not capable of functioning as a family physician (and they are not) - we have a situation where a new doctor has the choice between learning how to do aesthetics, and going through the "enhanced training" that allows him to function as a family physician. Which path do you think he will choose and why?
The bottom line here is that primary-care work, specifically the"managing chronic diseases in our ageing population" part, is not financially rewarding. Part of the problem lies with the fact that our healthcare system subsidises primary-care indiscriminately - you may not qualify for full subsidy under means testing in the wards, but you can still get full subsidy at the polyclinics, and be referred to a specialist as such, no questions asked. Such a situation distorts everyone's perception on what primary-care costs and is worth, and the result is what we are seeing today. (Ironically, SMA's effort in trying to encourage GPs to stay away from a high-volume low-quality care with the guidelines of fees was ruled anti-competitive.)
To a hammer, every problem is a nail. To a regulatory group, the solution to the problem is more regulations. The 'authorities', when presented to a problem, will always be tempted to 'do something'. Perhaps it's time MOH took a step back and looked at the economic realities that are present, and asked themselves whether their existing policies have made the practising of primary-care unattractive to GPs. If you can make it rewarding to them, the GPs will train themselves to become good family physicians (MOH don't provide enhanced training for GPs who want to do aesthetics, do they?); if you make it unrewarding to them, then why will they want to train to be a family physician at all?
Earlier this month, in the comments section of one of our posts, a reader disagreed with me that abuse of the healthcare system exists. She asked:
I believe no one likes to fall ill. No one wants to be sick. Therefore,
tell me who is there to abuse system?
Well, in his first blog post as Health Minister, Mr Gan Kim Yong writes:
We will have to review our funding framework, as well as the various financial assistance schemes, and make the necessary adjustments to ensure they remain appropriate and effective in helping Singaporeans cope with healthcare costs and yet prevent wastage or abuse.
Bravo.
Now this does not mean that the Health Minister *knows* that abuse exists, but it does mean that the feedback he received from healthcare workers is that it does exist; so if you think that the existence of abuse is merely a figment of my imagination, well, now you know.
To simply say: "let's subsidise more" is the populist and easy solution in the short term, but it does seem that Mr Gan is not going down that route.
Longtime readers of the blog will know that I am against our current subsidised healthcare system because of the lack of moral courage in policing and stopping abuse, and that the way to stretch our healthcare money is not to simply put more into the budget, but to cut waste. Will a new minister and new policies make me change my attitude towards subsidised healthcare? Well, we'll just have to wait and see, won't we?
A colleague recently remarked that being the (self opined “best”) expert that he was in his field, there was no one else he could discussed his cases with anymore. It is true that in this day and age you may end up as the only expert in your area (even internationally) especially if you sub (x n) specialize. However, whilst one might think one is the crème de la crème or the king of the hill, as a doctor, he must never assume that he can no longer learn from anyone. One can obviously turn to literature, research and international expert meetings but in truth, although background noise is aplenty, there are only that many substantial findings worth committing to memory, barring special breakthroughs. But when the science of medicine stagnates, it may be time for us to hone the art. Personally I find that I have learnt much from two groups of people.
It is an unfortunate (hard) truth that most doctors are narcissistic to begin with or will become one in the course of their training. It is already a daunting task to ask to experts to listen to one another much less to their undifferentiated juniors. However, this is silly as young bloods often have new ideas and have fresh eyes to some of the clinical problems we face. They are not burdened by the prejudices accumulated together with the years of experience and do not have preconceived notions. I often hear good ideas from MOs and Registrars and even if I may not agree with their ideas, it always good to listen to what opinions they have to offer when it comes to a difficult clinical scenario. Also, there are many junior Drs who may be extremely well liked by patients, receiving good comments (as well as cards and gifts) from them. I would observe (and learn from), albeit quietly, their mannerisms and attributes which endears them to their patients. The rapport that a doctor has with his patient often would make or break the management of the case and such soft skills had often been ignored by hardcore physicians and might not be the forte of many a senior Dr.
It may also come as a surprise that we often (consciously or unconsciously) learn from our patients. It does not matter how familiar you are with the literature, nothing beats having a firsthand account of the effects or side effects of a medication from a patient. We continue to learn about signs and symptoms presented in their many varied forms and often distorted in many ways by cultural overlays.
To illustrate, I had an elderly lady who came late for her appointment and complained of anxiety and itchiness in her womb. As she had been late and I was in a hurry to end my clinic, I was quick to dismiss her. My dismissive attitude continued for a few visits and I felt rather irritable with her persistent complaints of itchiness in the womb which I knew to be anatomically impossible. During one of her visits, my clinic was unusually empty and perhaps as I was less flustered that day, I chatted with her for an extended period of time. She told me that after her husband passed away, she had single handedly brought up her two children doing odd jobs. She had since retired as her children have all grown up and she was staying with her son, a successful engineer. Unfortunately, her daughter-in-law and her grandchildren found her uncouth and her son without putting in much thought was negotiating for her to move in her daughter. However, her daughter was not willing to take her in either due to space constraints. She was immensely disappointed and had worries that she would be abandoned. It became clear from her account was developing the anxiety due to the recent turmoil in her life particularly to the fear of being abandoned by her children. I felt ashamed of myself for having ignored this lady previously because she was late. Given her lack of education, she would have had difficulties maneuvering around our rather complicated hospital system to have made it to see me, thereby being late. More importantly, her accounts made me reflect on my own relationship with my parents.
It is important to sometimes slow down to look (at), listen (to) and feel (with) the people around our clinical practice. We may learn powerful lessons from the most unlikely person in the most unlikely place. For it may take ten years for one to become a fully accredited specialist but it will take a lifetime for us to master the art of medicine.
Dr BL Og
... then who have been 'affording' these pills?
